Transcript SURGICAL FORMS AND RECORDS

SURGICAL FORMS
AND RECORDS
TERMINAL OBJECTIVE:

Complete selected
forms and records
ENABLING OBJECTIVES

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1. Given simulated data, complete
surgical forms and records
2. Prepare surgical forms and
records for use during a surgical
procedure
PURPOSE:
Documentation
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Verbal communication
between patients and health
care providers does not
constitute legal evidence in a
court of law
Records identify what
occurred and what didn’t
occur
Purpose
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Means of communication between
providers during course of
treatment
Standard Form 515
(Tissue Examination)
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Intraoperative record of any tissue
or item removed from patient during
procedure
Can be used for more than one
tissue specimen
Appendix
Gallbladder
Bullet
Standard Form 515
(Tissue Examination)
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Labeled in the order removed
 Specimens labeled using letters
 First specimen labeled “A”,
etc… A
Standard Form 515
(Tissue Examination)
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Cultures labeled using numbers
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First culture labeled “1”, etc…
1
Standard Form 515
(Tissue Examination)
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Additional documentation is
required on any specimen that is
tagged identifying a specific margin
or location
Breast tumor
Standard Form 515
(Tissue Examination)
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Pertinent information required
 Surgeon’s name
 Name of specimen
 Clinical history
 Diagnoses:
Specimen Labels
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Addressographed self adhesive
labels
Used one per specimen obtained
during surgical procedure
Label made by patient runner or
nurse on arrival of patient to
holding area
Specimen Labels
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Clearly labeled with:
 Patient name
 Hospital register number
 Social Security number
 Type of specimen
 Operating room number
 Surgeon’s name
Standard Form 516
(Operation Report)

Records the number of personnel
involved inside that operating room
 Surgeon
 First/Second Assistant
 Anesthesia provider
 Nurses
 Technologists: Scrub, Circulator,
Students
Circulating nurse
Surgeon
1st assist
Student
scrub
2nd assist
Staff
scrub
Standard Form 516
(Operation Report)
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Pertinent information
Times
 Start and stops of:
 Anesthesia
 Operation
Diagnosis
 Preoperative
 Operative
Standard Form 516
(Operation Report)
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Sponge count
Drains
Operation
 Procedure performed
 Description
Standard Form 516
(Operation Report)
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Wound classification
Implants
Specimens
Cultures
Complications
Tourniquet times
Sponge, Needle, and Small
Count Sheet
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Hospital specific
Intraoperative for counted
items added to the sterile field
 Sponges
 Needles
 Small count items
Sponge, Needle, and Small
Count Sheet
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Technologist adding items to sterile
field should:
Initial above item added
 Place his/her signature in space
provided
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Sponge, Needle, and Small
Count Sheet
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Documentation of relief count is
done on bottom of worksheet
Completion of all appropriate
counts by O.R. nurse is
documented with word CORRECT
or INCORRECT on SF 516
Laboratory Requests
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Hematology
 CBC
 Differential
 Platelets
Microbiology
 Cultures/Smears
Blood Gas Analysis-ph
Standard Form 518
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Blood or Blood Component
Transfusion-used to request blood
and components
Can only be requested by:
 Medical/Dental officers
 Anesthesia providers
 Verbal order may be taken by
registered nurse
Newborn
paperwork
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Used during C-sections:
 Operating room
 L&D
Newborn I.D. Sheet
Baby’s ID band
Blood Bank/Cord Blood request
Serology request
Standard Form 522
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Request for Admission of
Anesthesia and Performance of
Operation/Other procedures
Informed consent to administer
anesthesia and perform operative
procedure
Standard Form 522
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Describes the procedure in
laymen’s terms
Signed:
 Patient
 Parent
 Legal guardian
Standard Form 522
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Witnessed by someone that is not a
member of the operating team.
Surgical procedure performed
without signed witnessed informed
consent
Standard Form 522
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Surgeon is ultimately responsible
for obtaining consent
Signed prior to pre-operative
medications
Standard Form 519-A
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Radiological Consultation Request
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Used for X-Rays to be taken
 Fractures
 Cholangiograms
 Placement of catheters
 Lost countable items
Incident Report
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Used to document an injury
to a patient or caregiver
 Complete and accurate
record of events
Part of departmental quality
improvement and risk
management program
REVIEW AND SUMMARY
SURGICAL FORMS
AND RECORDS
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If you didn’t write it down?
 It didn’t happen!
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THE END